Quality Corner--Part 6: It's a Team Effort

by Guest Column by James J. Augustine, MD, FACEP On Jun 1, 2011

The future of American healthcare is the development of accountable systems of care, and a great concept for quality improvement is to develop consolidated approaches to emergency care. Trauma systems have been built based on combined field and hospital data input, and this approach allows much better development of trauma databases and contributes to improved outcomes. That model is not expanding to patients presenting to EMS with cardiac arrests, acute myocardial infarctions and strokes. The challenge is to develop quality measures and statistics that extend to all patient groups, and improve the effectiveness and efficiency of the entire emergency system.

At a general level, EMS services and hospitals should share quality data. It helps them both collectively prepare reports to the community, local business leaders and, frankly, those nice people who might want to make financial contributions to improve emergency services (taxpayers, corporations, foundations and philanthropists). The combined statistics tell a great success story! The emergency system has reduced the impact of trauma, burn injuries, premature death from cardiac causes, and deaths from motor vehicle accidents. We have developed programs that produce real healthcare savings, from babies that are well-fitted in car seats and children protected by the use of bicycle helmets to caring for the needs of elderly persons living alone. We have launched programs to improve service to those in the community with mental health and substance abuse problems.

That is the story we put together in Dayton, OH. It convinced the largest local employer to quit talking badly about emergency care, persuaded a very generous family to give $8 million for a new trauma center, and allowed us to negotiate with local managed-care companies to pay for EMS nonremovals. Numbers matter, but data that tells a story to the community is what your quality program needs to produce.

Here's a multiple choice question:

Everyone knows EMS is abused, and patients routinely call ambulances for low-acuity medical problems. The percentage of patients who arrive by ambulance and are admitted from the emergency department into the hospital is:

A. 10% and decreasing

B. 15% and stable

C. 5% and decreasing

D. 40% and increasing

Across this country, the answer is D.

Yes, ambulances transport sick patients to hospitals, and almost half of them are so sick they can't be sent back home. What is the number in your community and for your service? Every EMS provider should know that number and be able to convey that important information to any news reporter, city administrator, county commissioner or taxpaying citizen. And every EMS QI program should develop a report that shows which patients are not transported in the community--something like, "Based on our historical data, we have 80% fewer cardiac arrests then we did 30 years ago, and 80% fewer children with head injuries, and 30% fewer auto accident victims." All true numbers!

The EMS and ED quality improvement staff should have collated statistics on how many patients utilize EMS, how many arrive at hospitals by EMS, and how many of those patients are admitted. A sampling would tell you what their demographics are and what services they receive. Over many years, there are trends in age, acuity and types of presentations. It has generally been older, sicker members of the community who are blessed to be living at home, and at times either hurt themselves or have exacerbations of diseases that require them to seek care urgently. The alternative to having more EMS runs for these types of patients is having more persons in hospitals or nursing homes. That is much more expensive, and not as friendly to people in those older population groups.

A growing number of large EMS systems are developing programs that improve service to frequent EMS users. This group of users can be defined by monthly or quarterly data reports that find the most frequent callers or addresses in the dispatch system. A special group of trained providers is empowered to contact frequent patients, evaluate their medical and social needs, and connect them with community- or hospital-based services that can meet their needs more appropriately then the EMS-ED access system. This group of patients should be characterized by decreasing use of EMS and ED services.

There are more joint data numbers that can be captured to help tell the story of the emergency care system. These are community-specific, but are important numbers to be collected and trended.

Prehospital times (response, scene and transport) less than 40 minutes;

Offload times less than 10 minutes, and ambulances back in service in less than 20 minutes;

More than 50% of acute myocardial infarctions arriving by EMS;

CPAP used for appropriate patients, and fewer than 10% of those patients need intubated in the ED;

Drug treatment used in more than 8% of EMS patients;

Nursing home patient transports decreasing as a percentage of total runs;

Patients with mental health and substance abuse issues have other treatment pathways than the EMS-ED system, and transports are decreasing as a percentage of total runs.

Cases where excellent care produced a better patient outcome. There should be three times as many compliments for good runs as runs where there are causes for review.

Case reviews for patients with an adverse outcomes. In peer-reviewed fashion, study them completely. Have some objective people review the run sheet and ED record, discuss the case with the medics and ED crew, and create a timeline of the case. Focus on ways in which system changes can improve outcomes.

Nontransported patients: There is a joint risk in nontransported patients. The hospital should track issues when patients present who for some reason did not come by EMS. Nontransports occur for a number of reasons, including the ability of EMS to refuse care, patient refusal, and issues around "no patient being found." Review some patient contacts that didn't result in transports (each still should have a record generated that includes the medic's evaluation). Study the refusals. Do you find any indication that patients are being talked out of going to the hospital, especially at late hours or at shift change?

Quality reviews on protocol compliance by both EMS and ED staff. The ED and EMS staffs should have EMS protocol reviews at least annually. Make sure new hires in all disciplines understand the protocols and demonstrate familiarity with them, including passing an exam.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. He is also a member of the EMS World editorial advisory board. Contact him at jaugustine@emp.com.